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Presented by Gabriela Moroney
Illinois Department of Healthcare and Family Services
March 29, 2016
The Protecting Access to Medicare Act of 2014
Established the Certified Community Behavioral Health Clinic (CCBHC) demonstration program.
Requires use of a Prospective Payment System (PPS) to pay selected clinics for CCBHC services provided to Medicaid enrollees.
PPS applies to CCBHC services delivered either directly by a CCBHC or through a Designated Collaborating Organization (DCO).
Illinois will implement the Certified Clinic PPS Alternative, also known as PPS-2, a cost-based, per clinic monthly rate.
PPS-2 requires at least one visit in a month to trigger a payment.
Monthly rate to reimburse CCBHC for services delivered to Medicaid enrollees.
Separate monthly rates to reimburse CCBHC for higher costs associated with providing all services needed to meet needs of clinic users with certain conditions.
Cost updates.
Outlier payments made in addition to PPS for participant costs in excess of thresholds defined by the state.
Quality bonus payments.
Illinois will establish monthly PPS rates that vary according to users’ clinical conditions.
Populations under consideration include (but are not limited to): Individuals with serious mental illness with degree of
functional impairment. Individuals with dually diagnosed mental illness and
substance use disorder with degree of functional impairment.
Individuals with substance use disorder and comorbid complex medical conditions.
Input on special populations will be sought from Steering Committee and Information Advisory Council.
Certain quality measures are required by federal Center for Medicaid Services (CMS), others are optional.
Illinois has option and intent to establish some additional quality measures, subject to CMS approval.
Input on quality metrics will be sought from Steering Committee and Information Advisory Council.
PPS-2 rates are cost-based.
Rates will be established through cost reports.
Rates will be updated through Medicare Economic Index and/or rebasing.
Develop cost report template to capture:
Costs, visits, and charges associated with demonstration services provided to all clinic users, not only Medicaid enrollees
Data to support cost allocation methods
Data about special populations
Secure federal approval for cost report template.
Selected CCBHCs complete cost report using: Population-specific cost data
Knowledge of accrual-based accounting
Understanding of Medicaid and Medicare cost principles
Understanding of how to enumerate visits under PPS-2
CCBHC CEO, CFO, Director, or a direct delegate certifies the cost report.
Estimations are allowed for initial reporting of costs.
Online materials for consideration
National Council’s CCBHC Certification Criteria Feasibility and Readiness Tool: http://www.thenationalcouncil.org/wp-content/uploads/2015/11/I-CCBHC-Feasibility-and-Readiness-Assessment-FINAL-REVISED-E-FORM12-8-15.pdf
Section C: PPS Rate Support Requirements
Section D: Other Considerations Related to CCBHC Feasibility and Readiness
Federal guidance: https://www.medicaid.gov/medicaid-chip-
program-information/by-topics/financing-and-reimbursement/223-demonstration-for-ccbhc.html
CMS PPS Guidance (part of RFA)
CCBHC Cost Report template and instructions* *This is only a sample; Illinois may develop unique template.
State receiving ongoing technical assistance from CMS.
State anticipates providing ongoing technical assistance to select CCBHCs to ensure straightforward implementation of PPS.
CCBHC States must demonstrate the capacity to collect
and report data in two categories.
• PPS claims and encounter data.
• Quality Measure Data.
• 17 CCBHC Required Quality Measures
• 15 State Required Quality Measures
• States must also Participate in National CCBHC
Evaluation.
• Tables containing required quality measures are
provided in Appendix A (p.65) of the SAMHSA
CCBHC RFA (SM-16-001).
• Need for further information regarding quality
measure operational definitions and reporting
specifications.
• It is expected that national evaluation contractor will
be identified in January 2017.
Next Steps… - RFI Due 12:00pm April 6th
- Questions
CCBHC Contact Information: [email protected]
http://www.dhs.state.il.us/page.aspx?item=29751
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